134 THE INDIAN MEDICAL GAZETTE. [March, 1925.

" sity College Hospital to Lister in 1853, Why, you must be in a perpetual state of bliss of the most aggra- vated description, operations being to you a foretaste Reviews. of the joys prepared for the good. We saw your name in the papers as an adopted child of Syme's, reporting a case for him." It was a not inaccurate description LORD LISTER.- By Sir Rickman John Godlee, Bt.? of the relationship between the two. K.C.V.O., M.S., F.R.C.S. 3rd edition, 1924. Oxford: Having married Syme's daughter, Agnes, and after a The Clarendon Press. Pp. 686. Illustrations 34- continental tour, Lister settled in Rutland Street in Price 21s. net. Edinburgh in 1856, and at once devoted himself to the remarkable 011 of in- i series of studies the pathology hp; medical man who to a idea of wishes gain clear flammation which preceded those of Metchnikoff, the broad foundations medicine upon which modern chiefly dealing with the vascular changes associated with and surgery are based should read two books great this process. In the same year, he commenced to lec- which are almost twin Radot's classics; Rene Vallery ture to students, his first class consisting of 23 pupils. Life of Pasteur" translation Mrs. Devon- (English by His lectures were entirely different in two ways from shire), and Sir the Rickman Godlee's "Lord Lister," those of his contemporaries; he taught far more patho- re-appearance of which in a third edition we cordially logy than \ surgery, and in place of academic lectures, welcome. Both are written studies of immortal finely had patients' brought into the lecture theatre one by one and deal with that of medical " subjects, splendid period as was also Syme's custom. He impressed us all when the work of the was clear- history great pioneers deeply from the beginning he worked us very hard ing the of the of and tradi- ground jungle empiricism he taught us pathology more than surgery. The and ex- tion, erecting the pillars of rationalism and was that he was a " general impression great thinker, and of perimental enquiry of the present-day temple he was treated as such by all the men," wrote Sir John medicine." Batty Tuke, one of Lister's pupils, in later years. Head and shoulders above them all in Great Britain The experiments on inflammation were succeeded rose the figure of the greatest and noblest of British by of a study of the conditions of blood coagulation and of surgeons, Joseph Lister (1827-1912). Something " spontaneous gangrene." this time he was known his nobility of spirit and glamour of personality may be By as a young surgeon of great promise, and a keen gathered from a quotation from his graduation address pupil of Syme's and in 1860 the chair of surgery at to students in 1876; "If we had nothing but pecuniary Glasgow University was offered to him and he accepted to rewards and worldly honours to look to, our profession it, be followed in 1861 as surgeon to the would not be one to be desired. But in its practice by appointment Here he contributed articles on you will find it to be attended with peculiar privileges; Royal Infirmary. and ana;sthetics to Holme's second to none in intense interest and pure pleasures. amputations System of and contributed technical on new It is our proud office to tend the fleshly tabernacle of Surgery, many papers technique and instruments to the medical journals. All the immortal spirit, and our path, if rightly followed, the his chief interest was in his labora- will be guided by unfettered truth and love unfeigned. time, however, tory and to him surgery rested upon the wide basis of In the pursuit of this noble and holy calling I wish you all God-speed." pathological study. In writes in an emi- The conditions of surgery in that day, however, are these pages Sir Rickman Godlee " nently readable and charming style of that wonderful now almost inconceivable. Any attempt to realise what teachers and students in career of 85 years, whilst the finely executed portraits' taught learned, and, fact, with which the volume abounds give an added interest what all doctors thought about hospital diseases in 1865, like to the state of mind of the to the volume. Lister was the son of a very remark- is trying appreciate inhabitants of this before had to able man, Joseph Jackson Lister a Quaker, a vintner, planet they begun doubt that it was the of the writes a Fellow of the Royal Society, and one who did much centre universe," Rickman was to bring microscopes and optical apparatus to their Sir Godlee. "Hospitalism rampant.... and the wards were dominated present day condition of perfection. Wisely, Sir Rick- surgical by erysipelas, and When a man Godlee allows Lister to tell much of his own story septicemia, gangrene. surgeon operated to was an his to the father to whom in those days, what he hoped obtain open in abstracts from long letters ' wound with laudable he was so devoted. It was customary in Lister's day streaming pusThe mortality rates after of limbs were 43 cent, at for predatory Scotch surgeons to qualify in the North amputation per cent, at and then to seek livelihood and fame in the more Edinburgh Infirmary, 39 per Glasgow Infirmary, and some 75 to 90 cent, in genial and more wealthy atmosphere of the Southern per military practice; Syme had as his reasoned conclusion that in kingdom. Li.=ter reversed this procedure; he qualified indeed given it all fractures of the lower immediate from University College Hospital, took the F.R.C.S. compound limb, to be resorted and no be (England) in 1852, and went to Edinburgh. Here he amputation ought to, attempt made to save the limb. The among women became house surgeon to that remarkable surgeon and mortality in child-birth was like wonderful teacher, James Syme, who welcomed such from puerperal sepsis something 1 in and in the land was a a recruit with open arms. Syme's consulting rooms 7, every lying-in hospital horrible focus of dirt and death. In many were in the city, but he had a charming house at Mill- hospitals or wards had had to be closed on bank, once a pleasant suburb of Edinburgh, but to-day surgical maternity of in frock swamped in the midst of its slums,?a house which account sepsis. Surgeons operated filthy coats encrusted with an accumulation of years of was the meeting place of a distinguished band of blood, and their assistants attempted to secure Edinburgh surgeons and intellectuals and foreign and pus dirt; equal- whilst the for operation were learned distinguished visitors. From the very com- ly filthy coats, ligatures carried, as badges of honour, in the buttonhole of the mencement Syme's influence and his system of clinical " of the coat. reigned supreme; I have teaching exercised the greatest influence upon the lappet Sepsis come to the wrote Cadge of Norwich, a career of Lister. Lister was exceedingly well qualified, conclusion," well known "that if it does not find as far as London standards then went; in Edinburgh, surgeon, pyaemia, its does find its natural home and resting- however, he found established a school of surgery birth-place, in if and although a hospital may not whith was far in advance of London standards, and in place hospitals; be the mother of it is its nurse." Erichsen, a Sir Rickman Godlee's pages we have here presented an pyemia, of the had written a interesting account of that celebrated Edinburgh school; distinguished surgeon day, just book in which he claimed that surgery had reached also indeed of the very acrimonious controversies which it was too to the abdominal abounded between the chief protagonists of the day, finality; dangerous open " or other and all that remained in the way Edinburgh, Syme, super-house-surgeon," wrote body cavity, of future was to the of the Sir George Buchanan, his fellow student, from Univer- progress improve technique March, 1925.] REVIEWS. 135

the limbs. then-existant operations upon Leibig, the wound out with it after operation, and covering it with that in a wound German chemist, taught suppuration a small dressing of lint soaked in the crude acid and access to of the was due to the it oxygen of the air; covered with a sheet of tin or lead foil in order to and matters this could not possibly be excluded, hence keep the volatile acid in contact with the wound. The could All sorts of measures were not be improved. result was to produce a sterile scab, under which the tried; giving a greatly increased space to the beds in wound healed aseptically. the wards, immersing operated-upon limbs in surgical He soon realised, however, that the crude undiluted continuous water baths, testing different drugs and reme- acid was unsuitable, and commenced to use lotions of dies in solution in dressings; nothing succeeded. Con- 1 in 20 and 1 in 40 strength ; strengths which we to-day ditions were such as to appal Lister and every other recognise as still irritant to the tissues. In 1867 he surgeon of the day. Lister was busy with a thinking the first of his famous papers upon the anti- of the exact position of the abdominal, aorta and published study principle, giving the wonderful results obtained the details of excision of the wrist, but his septic thoughts in his first series of 11 cases of compound fracture were continuously upon the subject of inflammation treated with carbolic acid. Also he now introduced a and suppuratioi], his laboratory hours continuously second principle into surgery; previously it had been spent upon devices to combat sepsis. customary to leave the ends of ligatures long, so that Meantime, however, upon the continent matters they hung out of the angle of the wound, and were if in accordance almost with some moved?as great fore removed as they sloughed off. Confident in his anti- their ordained plan?to appointed end. Semmelweis in septic technique, Lister began to cut the ligatures short Vienna made the remarkable observation that, in a large and to leave them buried in situ. It was a second new the chief from lying-in hospital, mortality puerperal principle in surgery, of importance only secondary to fever occurred when the attendant physicians went from the introduction of the antiseptic principle. the post-mortem room to the and that lying-in wards, Subsequent to the introduction of the antiseptic prin- septicaemia and puerperal fever were identical diseases; ciple, the evolution of modern surgery was bath rapid also that the was lower in the mortality wards where and brilliant. Lister introduced the carbolic spray,? the attendants were all who did not attend the females, at first in the form of the hand spray, later of the and in the wards post-mortem room, highest where mechanically worked "donkey engine," still later the students attended who had visited the post-mortem room. steam spray. Under these sprays the atmosphere He was and of his ridiculed, persecuted, deprived around the operation wound was saturated with the he died in a lunatic asylum; but appointment; to-day vapour from a 1 in 20 solution of carbolic acid in the his memory is honoured throughout Europe. hope of killing germs which might have access to the In France, Louis Pasteur had been steadily at work. wound. Also he was continuously at work trying to The fermentation of beers, taught Leibig, is due to the improve the dressings of the wound, the principle being presence within them of dead yeasts; the yeasts, upon to a first which should contain carbolic apply dressing " " dying, liberate a catalytic agent which causes the fer- acid, then to cover this with a protective impermeable mentation. Fermentation, upon the other hand, taught dressing such as oiled silk which should prevent loss of Pasteur, is not due to dead yeasts at all, but to living the antiseptic by volatilisation; and the cerate dressing, and multiplying yeasts, which require sugar for their the putty dressing, carbolised gauze, and finally the and in the course of their nutrition, metabolism produce double cyanide gauze which is to-day in such frequent from it. It was the first a alcohol echo of controversy use, followed. which convulsed Europe for years; in France the battle Lister's struggle, however, to establish the new being between Pasteur and Pouchet, in England be- prin- ciple was a long and bitter one. Gradually there grew tween Tvndall and Bastian. Life, taught Pasteur, " up a yoiinger generation of surgeons, many of them comes only from pre-existing life; le germe e'est la his own who abroad and who themselves vie, et la vie e'est le germe." Sepsis in wounds, he pupils, spread practised the new doctrine. Thus at Edinburgh pro- claimed, is due to germs from the air or from the dirty gress was whilst several of the staff at Glasgow hands of the surgeon or his assistants being introduced rapid, became converts to his ideas. In Germany especially into them; and he proceeded to further matters by his was surgery taken up with enthusiasm. In discoveries of the staphylococcus and the streptococcus. antiseptic progress was far slower, and the suf- were France, however, At that time "antiseptics" already recognised, ferings of the French wounded during the Franco- meant far but the word then something different from Prussian war of 1870 under the old regime of " " sepsis what we mean by it to-day; in those days an anti- In " and filth were indescribable. London listerism" was some or other which to septic drug might help was generally sneered at. Many of the older surgeons, reduce already pre-existing sepsis; to-day we use it especially Sir James Simpson, Lawson Tait in Birming- for a drug which will prevent sepsis from occurring. ham, Nunneley, and Savory, attacked Lister. His ideas had for some been Lister years carefully feeling his and views were entirely misrepresented; he was accused to the introduction of antiseptics in way surgical prac- of trying to lay claim to be the first surgeon to use but Pasteur's views at once him " tice, published gave carbolic acid, his methods were tested" in a half- clue. If Pasteur was if the necessary right, suppura- hearted method with bad results; that what Lister had was due to from outside tion germs being introduced done was to introduce a new idea and a new clean principle into an otherwise surgically wound, matters were was grasped by none of his the must be critics; to-day echoes simplified. Some substance used which would of that fierce sound almost their controversy incredible. For kill all such germs and prevent access to the wound sneered example, Lawson Tait at antiseptic surgerv to made and after the operation. during the day of his death; yet in his own practice Tait "used The antiseptic principle introduced by Lister was a technique which was an approximation to the aseptic something quite new. It was not the attempt to over- method, repeatedly washing his hands and pouring had been as of warm boiled water into come sepsis which already _ established, gallons the peritoneal cavity some of his contemporaries misrepresented the case; with which to flush it. Yet, despite a fierce and almost nor did it consist in the introduction of carbolic acid unanimous opposition from the older school, antiseptic It was a lotions in surgical practice. new method, a surgery gradually became more and more universally new visualisation, a new procedure, based upon experi- practised on account of its excellent results: mental Several surgeons prior to Lister had pathology. Lister had created antiseptic surgery; his use of the used carbolic Lemaire had its value acid, investigated short ligature had revolutionised surgical practice; yet as an and it was in use,?in the crude form "antiseptic," a third great problem faced him; that of the best of that as a deodorant for the treatment of the day,? method of arresting haemorrhage in aseptic wounds. introduced it sur- sewage of Carlisle. Lister _ into his From 1867 he was continuously at work investigating gical and upon it in his labora- practice experimented the best methods of preparing and sterilising catgut, At first he used the crude acid, the tory. swabbing work which led to the modern chromicised ligature. 136 the INDIAN MEDICAL GAZETTE. [March, 1925.

introduction of an absorbable in of The ligature, place 1876 he gave the graduation address at Edinburgh, thread the old-fashioned one, again almost revolution- emphasising in a very remarkable address to students he was ised surgical practice. Again misrepresented; the high standards and privileges of the medical pro- claimed was that the was what lie catgut invaded and fession ; and in 1877 lie moved to London, on appoint- subsequently replaced by fibrous tissue; what his ment to the chair in clinical surgery at King's College opponents said he claimed was that the catgut was Hospital. absorbed by the body fluids. In. chapters 16 to 22, In London, Lister found an almost hostile atmos- Sir Ricknjan Godlee gives a vivid and very interesting phere ; London indeed was far behind both Scotland and account of the fierce controversies out of which the. the continent in its acceptance of his views. Also his antiseptic method arose, to be finally almost reintro- unpunctuality at appointments and his curious preference duced into England from Germany in improved form. for leaving the amount of the fee to his patient to In 1869 he was appointed professor of clinical sur- decide were against him in private practice. Yet he gery in Edinburgh; in 1869 his father died, and in opened his campaign with a minimal number of both 1870 his great friend Syme. By degrees the work_ in students and beds, and he taught bacteriology and patho- his laboratory became more and more bacteriological, logical fundamentals, rather than operative surgery. experiments to confirm Pasteur's views on the germ Addresses to the Pathological Society and to the theory, and a study of lactic acid This Harveian Society followed. In 1877 he wired a broken fermentation.^ " brought him into correspondence with the great French knee-cap by open operation,?a novel procedure. Now is genius, and led to a medical entente cordiale, which it when this poor fellow dies," remarked one of his col- later " pleasant and refreshing to look back upon in these leagues, it is proper that someone should proceed days when the two great nations have stood shoulder against Lister for malpraxis." But the patient did not to shoulder through war and suffering, and have learned die, healing took place by what Lister now termed "the to appreciate each other better. One of the chief ex- usual aseptic course"; the expected catastrophe was ponents of the germ theory in Great Britain was the averted. studies the great physicist Tyndall, whose optical upon In 1881 there was held the ever-memorable Seventh dust of the and whose lectures to atmosphere popular International Medical Congress in London; when Volk- audiences did much to familiarise the populace at lay mann in a brilliant address hailed Lister and the glory with the large germ theory. of England as being indissolubly bound with the great- A still further in technique in- improvement surgical est advance that surgery, had ever made. Pasteur also troduced Lister in 1871 was the introduction of by paid his tribute to the great surgeon, and by now it when had " rubber drainage tubes. Previously, ligatures could be claimed that listerism" had triumphed; its been left and out of the angle of the long hanging opponents were in the background; whilst Lister him- wound, it was that these might improve drain- thought self in his final address upon the method and principle blocked with clot and pro- age. Actually they became summarised his views and the struggle of the past vided no at all. The has often been drainage story years. told of liovv Lister, when operating for axillary abscess There followed between upon Queen Victoria herself, during a stay at Balmoral, the?supposed?controversy where the use of anti- took a bit of rubber tubing from the spray apparatus antiseptic surgery, by strong the to kill all which used to produce local anaesthesia, and used it as a septics attempt is made germs may have access to a and the drainage tube. wound, aseptic surgery, to heat and other means the Whilst it was chiefly in the provinces in Great Britain attempt prevent by physical access of at all to the wound. As Sir Rick- that the antiseptic system spread, in Germany it took any germs man Godlee such a is deep root. Volkmann was a doughty champion; rightly claims, controversy to-day of but barren the one method is but the Stromcyer playfully summarised the situation in the interest; logical of the other. In actual the following lines to Lister:? development fact, indeed, " asepticists use very strong antiseptics, iodine with Mankind looks now on thee grateful which to sterilise the skin, bioniodide lotion for the For what thou didst in surgery. operator's hands, and so forth. He proclaims himself And Death must often go amiss, as a follower of the rather than the bliss." frankly antiseptic By smelling antiseptic aseptic school. And here?in chapter 27?is much The Munich hospital was notorious for its terrible valuable writing of special interest to the reader in condition of "hospitalism," hospital gangrene occur- India. We cannot but consider that .Sir Richman ring in no less than 80 per cent, of all wounds, whether Godlee is right. The aseptic method is only ^suitable in of natural origin or inflicted by the surgeon. The large and well equipped institutions. The long chain abolished from introduction of Lister's methods sepsis of subordinates upon which the success of the aseptic the at and von institution. Von Bergman Wiirzburg, method depends is a very 'vulnerable one. Dressings Volkmann, and Billroth of Vienna became enthusiastic arc sent out in sealed and sterilised packages by manu- in disciples of "listerism"; whilst Saxtorph Copen- facturers ; catgut comes from Heaven alone knows sur- hagen was one of the first to introduce antiseptic where; there is an army of theatre sisters, nurses, on with gery the continent of Europe. By degrees, assistants and subordinates, every one of whom must confirmation of its value on the continent, and in practise an absolutely aseptic technique if sepsis is to America chiefly in the hands of R. F. Weir, the prin- be avoided. In actual practice he doubts whether the and ciples of antiseptic surgery became internationalised aseptic technique gives better results than does the anti- of the British established. In 1875 the annual meeting septic one. (For our own part, and as regards the Medical Association was held in Edinburgh, an event small in with few or no skill- " mofussil hospitals India, which did much to establish listerism" as the guiding ed assistants and a minimum of equipment, we have no of British principle surgery. doubts; antiseptics may be irritating to the tissues, but the same came the full is a counscl of and In year the now famous correspondence v aseptic technique perfection with Queen Victoria regarding the value of vivisection impossible of attainment.) in experimental medicine; a controversyi in which, des- Space dues not permit our following further Sir Rick- pite his position as Surgeon in Scotland to Her man Godlee's fascinating story of this greatest of British did not flinch Majesty, Lister from expressing his surgeons. His baronetcy was conferred upon him in emphatic views that such experimentation was not only 1883; an honour which was especially noteworthy but even for the essential necessary study of diseases, among the very small number of medical baronets who even those of animals themselves. The student of had been created at that day. In London in general his to-day will find in these pages of Sir Rickman Godlee's life was easier and with more leisure in it than in book valuable and emphatic expression by Lister him- Edinburgh; his hours more given to his laboratory and self of what he owed to experiments upon animals in to his "connnon-place books", (notebooks and records). the development of modern surgery and medicine. In In 1887, together with Sir Victor Ilorsley and many of I March, 1925.] ANNUAL REPORTS. 137

the leading medical men of the conntry, he was appoint- ed a member of the Commission sent to Paris to study Pasteur's anti-rabic methods; a Commission which resulted in the Muzzling Order and the extirpation of rabies from Great Britain; in 1893 the celebrated Lister Institute at Chelsea was opened, in the teeth of oppo- sition from antivivisectionists and of lethargy on the part of government officials, and by public subscription; to be subsequently set upon a sound financial basis by Lord Iveagh's noble endowment of ?250,000 in 1900. In 1887 came the historic scene at the Pasteur jubilee at the Sorbonne in Paris, when Pasteur and Lister,? the latter representing' the Royal Society of London and that of Edinburgh?were the two honoured guests, a celebration immortalised in the etching by Rixens; whilst in 1895 he became President of the Royal Society, a position only once previously held by a sur- geon (Sir Benjamin Brodie, 1858-61). In 1893 Lady Lister died, his intimate companion, secretary and fellow-worker for 37 years. From that time onwards Lister lived a solitary, secluded and sad- dened life. The laboratory work, the addresses to learned and scientific societies, and his keen and critical experimental work continued, but he withdrew more and more from social and public life. Honours des- cended upon him and his 80th birthday in 1907 was celebrated all over the world. In 1912 he died, and? in spite of his personal wishes was buried in West- minster Abbey, where Sir Thomas Brock's medallion of him is for ever memorable. The anthem at the funeral service was singularly appropriate:? " When the ear heard him, then it blessed him; and when the eye saw him, it gave witness of him; he deli- vered the poor that cried, the fatherless, and him that had none to help. Kindness, meekness, and comfort were in his tongue. If there was any virtue, and if there was any praise, he thought on these things. His body is buried in peace, but his name liveth for ever- more." Sir Rickman Godlee's fine and scholarly book is a memorable tribute to an immortal subject. We cannot live again those glorious days of the great past; but in its pages we can catch again somewhat of their glamour, of their nobility, and of the great and heroic figure who created and rendered possible modern " surgery,?a knight of modern days, sans peur et sans reproche." R. K.